Future year (2028) source apportionment modeling to support Regional Haze Rule planning in the western U.S.

The Western Regional Air Partnership (WRAP) has developed a modeling platform to simulate the formation of haze-causing particles that impact federally-protected lands in the western United States. To assist state air quality planners in determining which emission sources are likely candidates for future mitigation, several source apportionment scenarios were evaluated, and two sets of results for the year 2028 are presented here: 1) a "high-level important regional sources" version, with broad emission categories (i.e. U.S. anthropogenic, international anthropogenic, natural, and fires), and 2) a "low-level anthropogenic emission sources within individual states" version, which refines the U.S. anthropogenic contribution to specific emission sectors within individual WRAP region states. Eight examples are discussed, which reflect the variation in source apportionment results at national parks, wilderness areas, and wildlife refuges in the western U.S. and suggest which emission sectors are candidates for mitigation to improve future visibility. In 2028, the contribution of domestic anthropogenic emissions at the eight sites ranges from 17% to 58%, with significant impacts from oil and gas production, fossil fuel electric generation, and federally-regulated mobile sources. The contribution from international anthropogenic sources can also be considerable, and ranges from 17% to 43%. Most sectors that are emitting sulfur dioxide (SO2) and nitrogen oxides (NOx), which are the two most likely particle precursors to be curtailed in the states' Regional Haze plans, are declining. For example, in the 13 contiguous WRAP region states, NOx emissions from on-road mobile sources and electric generating units (EGUs) declined by 738 kton/yr (29% decrease) and 65 kton/yr (31% decrease), respectively, in 2028 as compared to current emission estimates, and SO2 emissions from EGUs declined by 42 kton/yr (29% decrease). NOx emissions from oil and gas development also declined by 25 kton/yr (9% decrease) but rose for SO2 emissions by 12 kton/yr (20% increase).Implications: The goal of the Regional Haze Rule (RHR) is to improve visibility at federally-protected areas, and to eventually arrive at natural conditions by the year 2064. Source apportionment tools within regional air quality models are useful for identifying which emission regions and sectors are contributing to haze-causing particles and can indicate to air quality planners where additional emission controls may be warranted.

Transforming Clinical Practice Initiative Boosted Participation in Medicare Alternative Payment Models.

The Centers for Medicare & Medicaid Services' (CMS's) Transforming Clinical Practice Initiative (TCPi) was the largest national-scale practice transformation model. We analyzed the effect of TCPi on new enrollment into Medicare Alternative Payment Models (APMs) through January 2020 (3 months after program end), using 6958 physician practices enrolled in TCPi and a closely matched comparison group of 6958 practices. More TCPi practices enrolled in Medicare APMs and Medicare Advanced APMs relative to comparison practices overall and in subgroups, including rural, small, and specialty practices. Results suggest that large-scale technical assistance can boost participation in Medicare APMs for a diverse set of practices.

Effect of the Million Hearts Cardiovascular Disease Risk Reduction Model on Initiating and Intensifying Medications: A Prespecified Secondary Analysis of a Randomized Clinical Trial.

Importance: The Million Hearts Cardiovascular Disease (CVD) Risk Reduction Model pays provider organizations for measuring and reducing Medicare patients' cardiovascular risk. Objective: To assess whether the model increases the initiation or intensification of antihypertensive medications or statins among patients with blood pressure or low-density lipoprotein (LDL) cholesterol levels above guideline thresholds for treatment intensification. Design, Setting, and Participants: This prespecified secondary analysis of a cluster-randomized, pragmatic trial included primary care and cardiology practices, health care centers, and hospital-based outpatient departments across the US. Participants included Medicare patients who were enrolled into the model in 2017 by participating organizations and who were at high risk and at medium risk of a myocardial infarction or stroke in 10 years. Patient outcomes were analyzed for 1 year postenrollment (through December 2018) using an intent-to-treat design. Analysis began November 2019. Interventions: US Centers for Medicare & Medicaid Services paid organizations for risk stratifying Medicare patients and reducing CVD risk among high-risk patients through discussing risk scores, developing individualized risk reduction plans, and following up with patients twice yearly. Main Outcomes and Measures: Initiating or intensifying statin or antihypertensive therapy within 1 year of enrollment, measured in Medicare Part D claims, and LDL cholesterol and systolic blood pressure levels approximately 1 year after enrollment, measured in usual care and reported to Centers for Medicare & Medicaid Services via a data registry (data complete for 51% of high-risk enrollees). The study's primary outcome (incidence of first-time myocardial infarction and stroke) is not reported because the trial is ongoing. Results: A total of 330 primary care and cardiology practices, health care centers, and hospital-based outpatient departments and 125 436 Medicare patients were included in this analysis. High-risk patients in the intervention group had a mean (SD) age of 74 (4.1), 15 213 (63%) were male, 21 657 (90%) were receiving antihypertensive medication at baseline, and 16 558 (69%) were receiving statins. Almost all (21 791 [91%]) high-risk intervention group patients had above-threshold systolic blood pressure level (>130 mm Hg), LDL cholesterol level (>70 mg/dL), or both. Patients in the intervention group with these risk factors were more likely than control patients (8127 [37.3%] vs 4753 [32.4%]; adjusted difference in percentage points, 4.8; 95% CI, 2.9-6.7; P < .001) to initiate or intensify statins or antihypertensive medication. Centers for Medicare & Medicaid Services did not pay for CVD risk reduction for medium-risk enrollees, but initiation or intensification rates for these enrollees were also higher in the intervention vs control groups (12 668 [27.9%] vs 7544 [24.8%]; adjusted difference in percentage points, 3.1; 95% CI, 1.9-4.3; P < .001). Among high-risk enrollees with clinical data approximately 1 year after enrollment, LDL cholesterol level was slightly lower in the intervention vs control groups (mean [SD], 89 [31.8] vs 91 [32.1] mg/dL; adjusted difference in percentage points, -1.8; 95% CI, -2.9 to -0.6; P = .002), as was systolic blood pressure (mean [SD], 133 [15.7] vs 135 [16.4] mm Hg; adjusted difference in percentage points, -1.7; 95% CI, -2.8 to -0.6; P = .003). Conclusions and Relevance: In this study, a pay-for-performance model led to modest increases in the use of CVD medications in a range of organizations, despite high medication use at baseline.

The Effectiveness of a Peer-Staffed Crisis Respite Program as an Alternative to Hospitalization.

OBJECTIVE: This study assessed whether peer-staffed crisis respite centers implemented in New York City in 2013 as an alternative to hospitalization reduced emergency department (ED) visits, hospitalizations, and Medicaid expenditures for individuals enrolled in Medicaid. METHODS: This study used Medicaid claims and enrollment data for January 2009 through April 2016 to estimate impacts on ED visits, hospitalizations, and total Medicaid expenditures by using a difference-in-differences model with a matched comparison group. The study sample included 401 respite center clients and 1,796 members of the comparison group. RESULTS: In the month of crisis respite use and the 11 subsequent months, Medicaid expenditures were on average $2,138 lower per Medicaid-enrolled month and there were 2.9 fewer hospitalizations for crisis respite clients than would have been expected in the absence of the intervention (p<.01). CONCLUSIONS: Peer-staffed crisis respite services resulted in lowered rates of Medicaid-funded hospitalizations and health expenditures for participants compared with a comparison group. The findings suggest that peer-staffed crisis respites can achieve system-level impacts.

Enlarging nodule under the toenail · no history of trauma · unremarkable medical history · Dx?

A 28-year-old woman with an unremarkable medical history presented with an enlarging nodule that had been growing under her left great toenail for 6 months. The patient monitored the nodule, hoping that it would resolve on its own, but found that it steadily increased in size and began to displace the nail, causing pain. At the time of presentation, the nodule measured approximately 10 mm in diameter, and there was significant (~80°) superior displacement of the nail.

The Impact of a Health Information Technology-Focused Patient-centered Medical Neighborhood Program Among Medicare Beneficiaries in Primary Care Practices: The Effect on Patient Outcomes and Spending.

BACKGROUND: The Center for Medicare & Medicaid Innovation (CMMI) tests new models of paying for or delivering health care services and expands models that improve health outcomes while lowering medical spending. CMMI gave TransforMED, a national learning and dissemination contractor, a 3-year Health Care Innovation Award (HCIA) to integrate health information technology systems into physician practices. This paper estimates impacts of TransforMED's HCIA-funded program on patient outcomes and Medicare parts A and B spending. RESEARCH DESIGN: We compared outcomes for Medicare fee-for-service (FFS) beneficiaries served by 87 treatment practices to outcomes for Medicare FFS beneficiaries served by 286 matched comparison practices, adjusting for differences in outcomes between the 2 groups during a 1-year baseline period. We estimated impacts in 3 evaluation outcome domains: quality-of-care processes, service use, and spending. RESULTS: We estimated the program led to a 7.1% reduction in inpatient admissions and a 5.7% decrease in the outpatient emergency department visits. However, there was no evidence of statistically significant effects in outcomes in either the quality-of-care processes or spending domains. CONCLUSIONS: These results indicate that TransforMED's program reduced service use for Medicare FFS beneficiaries, but also show that the program did not have statistically significant favorable impacts in the quality-of-care processes or spending domains. These results suggest that providing practices with population health management and cost-reporting software-along with technical assistance for how to use them-can complement practices' own patient-centered medical home transformation efforts and add meaningfully to their impacts on service use.

Uses and Limitations of Claims-based Performance Feedback Reports: Lessons From the Comprehensive Primary Care Initiative.

BACKGROUND: Performance feedback is central to data-driven models of quality improvement, but the use of claims-based data for feedback has received little attention. PURPOSE: To examine the challenges, uses, and limitations of quarterly Medicare claims-based performance feedback reports generated for practices participating in the Comprehensive Primary Care (CPC) initiative from 2012 to 2015. METHODS: Mixed methods study of nearly 500 CPC practices in seven regions, combining pilot testing; systematic monitoring; surveys; in-depth interviews; user feedback; and input from data feedback team. RESULTS: Designing reports required addressing issues about timing, data completeness and reliability, variations in patient risk across practices, and use of benchmarks and metrics understandable to users. Practices' ability to use reports constructively depended on their experience, analytic resources, expectations, and perceptions about the role of primary care in improving reported outcomes. CONCLUSIONS: Generating claims-based feedback reports that support practices' quality improvement efforts requires a significant investment of analytic expertise, time, resources, continuous improvement, and technical assistance. IMPLICATIONS: Claims-based performance feedback can provide insight into patterns of patients' care across provider settings and opportunities for improvement, but practices need data from other sources to manage patients in real time or assess the short-term effects of specific changes in care delivery.

Origin of Fine Particulate Carbon in the Rural United States.

Carbonaceous compounds are a significant component of fine particulate matter and haze in national parks and wilderness areas where visibility is protected, i.e., class I areas (CIAs). The Regional Haze Rule set the goal of returning visibility in CIAs on the most anthropogenically impaired days to natural by 2064. To achieve this goal, we need to understand contributions of natural and anthropogenic sources to the total fine particulate carbon (TC). A Lagrangian chemical transport model was used to simulate the 2006-2008 contributions from various source types to measured TC in CIAs and other rural lands. These initial results were incorporated into a hybrid model to reduce systematic biases. During summer months, fires and vegetation-derived secondary organic carbon together often accounted for >75% of TC. Smaller contributions, <20%, from area and mobile sources also occurred. During the winter, contributions from area and mobile sources increased, with area sources accounting for half or more of the TC in many regions. The area emissions were likely primarily from residential and industrial wood combustion. Different fire seasons were evident, with the largest contributions during the summer when wildfires occur and smaller contributions during the spring and fall when prescribed and agricultural fires regularly occur.

Modeling to Evaluate Contribution of Oil and Gas Emissions to Air Pollution.

Oil and gas production in the Western United States has increased considerably over the past 10 years. While many of the still limited oil and gas impact assessments have focused on potential human health impacts, the typically remote locations of production in the Intermountain West suggests that the impacts of oil and gas production on national parks and wilderness areas (Class I and II areas) could also be important. To evaluate this, we utilize the Comprehensive Air quality Model with Extensions (CAMx) with a year-long modeling episode representing the best available representation of 2011 meteorology and emissions for the Western United States. The model inputs for the 2011 episodes were generated as part of the Three State Air Quality Study (3SAQS). The study includes a detailed assessment of oil and gas (O&G) emissions in Western States. The year-long modeling episode was run both with and without emissions from O&G production. The difference between these two runs provides an estimate of the contribution of the O&G production to air quality. These data were used to assess the contribution of O&G to the 8 hour average ozone concentrations, daily and annual fine particulate concentrations, annual nitrogen deposition totals and visibility in the modeling domain. We present the results for the Class I and II areas in the Western United States. Modeling results suggest that emissions from O&G activity are having a negative impact on air quality and ecosystem health in our National Parks and Class I areas. IMPLICATIONS: In this research, we use a modeling framework developed for oil and gas evaluation in the western United States to determine the modeled impacts of emissions associated with oil and gas production on air pollution metrics. We show that oil and gas production may have a significant negative impact on air quality and ecosystem health in some national parks and other Class I areas in the western United States. Our findings are of particular interest to federal land managers as well as regulators in states heavy in oil and gas production as they consider control strategies to reduce the impact of development.

Physician EHR Adoption and Potentially Preventable Hospital Admissions among Medicare Beneficiaries: Panel Data Evidence, 2010-2013.

OBJECTIVE: To test for correlation between the growth in adoption of ambulatory electronic health records (EHRs) in the United States during 2010-2013 and hospital admissions and readmissions for elderly Medicare beneficiaries with at least one of four common ambulatory care-sensitive conditions (ACSCs). DATA SOURCES: SK&A Information Services Survey of Physicians, American Hospital Association General Survey and Information Technology Supplement; and the Centers for Medicare & Medicaid Services Chronic Conditions Data Warehouse Geographic Variation Database for 2010 through 2013. STUDY DESIGN: Fixed effects model estimated the relationship between hospital referral region (HRR) level measures of physician EHR adoption and ACSC admissions and readmissions. Analyzed rates of admissions and 30-day readmissions per beneficiary at the HRR level (restricting the denominator to beneficiaries in our sample), adjusted for differences across HRRs in Medicare beneficiary age, gender, and race. Calculated physician EHR adoption rates as the percentage of physicians in each HRR who report using EHR in ambulatory care settings. PRINCIPAL FINDINGS: Each percentage point increase in market-level EHR adoption by physicians is correlated with a statistically significant decline of 1.06 ACSC admissions per 10,000 beneficiaries over the study period, controlling for the overall time trend as well as market fixed effects and characteristics that changed over time. This finding implies 26,689 fewer ACSC admissions in our study population during 2010 to 2013 that were related to physician ambulatory EHR adoption. This represents 3.2 percent fewer ACSC admissions relative to the total number of such admissions in our study population in 2010. We found no evidence of a correlation between EHR use, by either physicians or hospitals, and hospital readmissions at either the market level or hospital level. CONCLUSIONS: This study extends knowledge about EHRs' relationship with quality of care and utilization. The results suggest a significant association between EHR use in ambulatory care settings and ACSC admissions that is consistent with policy goals to improve the quality of ambulatory care for patients with chronic conditions. The null findings for readmissions support the need for improved interoperability between ambulatory care EHRs and hospital EHRs to realize improvements in readmissions.

Variations in enzymatic hydrolysis efficiencies for amitriptyline and cyclobenzaprine in urine.

A collaborative study was conducted to investigate discrepancies in recoveries of two commonly prescribed compounds, amitriptyline and cyclobenzaprine, in patient urine samples when hydrolyzed with different enzymes from different sources. A 2- to 10-fold increase in analyte recoveries was seen for patient samples hydrolyzed using a recombinant ß-glucuronidase (IMCSzyme™) over samples hydrolyzed with ß-glucuronidase from Haliotis rufescens We report outcomes from four commercially available ß-glucuronidase enzymes (IMCSzyme™, Patella vulgata, Helix pomatia and H. rufescens) on patient samples that tested positive for amitriptyline and cyclobenzaprine. Our results confirm reduced hydrolysis of glucuronides by ß-glucuronidases isolated from mollusks, but near complete conversion when using the recombinant enzyme. Our premise is that systematic differences in hydrolysis efficiencies due to varying substrate affinity among enzyme subtypes potentially impacts accuracy and reliability of measurements.

The Affordable Care Act and Access to Care for People Changing Coverage Sources.

OBJECTIVES: We investigated how access to and continuity of care might be affected by transitions between health insurance coverage sources, including the Marketplace (also called the Exchange), Medicaid, and the Children's Health Insurance Program (CHIP). METHODS: From January to February 2014 and from August to September 2014, we searched provider directories for networks of primary care physicians and selected pediatric specialists participating in Marketplace, Medicaid, and CHIP in 6 market areas of the United States and calculated the degree to which networks overlapped. RESULTS: Networks of physicians in Medicaid and CHIP were nearly identical, meaning transitions between those programs may not result in much physician disruption. This was not the case for Marketplace and Medicaid and CHIP networks. CONCLUSIONS: Transitions from the Marketplace to Medicaid or CHIP may result in different degrees of physician disruption for consumers depending on where they live and what type of Marketplace product they purchase.

Aerosol species concentrations and source apportionment of ammonia at Rocky Mountain National Park.

Changes in ecosystem function at Rocky Mountain National Park (RMNP) are occurring because of emissions of nitrogen and sulfate species along the Front Range of the Colorado Rocky Mountains, as well as sources farther east and west. The nitrogen compounds include both oxidized and reduced nitrogen. A year-long monitoring program of various oxidized and reduced nitrogen species was initiated to better understand their origins as well as the complex chemistry occurring during transport from source to receptor. Specifically the goals of the study were to characterize the atmospheric concentrations of nitrogen species in gaseous, particulate, and aqueous phases (precipitation and clouds) along the east and west sides of the Continental Divide; identify the relative contributions to atmospheric nitrogen species in RMNP from within and outside of the state of Colorado; identify the relative contributions to atmospheric nitrogen species in RMNP from emission sources along the Colorado Front Range versus other areas within Colorado; and identify the relative contributions to atmospheric nitrogen species from mobile sources, agricultural activities, and large and small point sources within the state of Colorado. Measured ammonia concentrations are combined with modeled releases of conservative tracers from ammonia source regions around the United States to apportion ammonia to its respective sources, using receptor modeling tools.

Regional impacts of oil and gas development on ozone formation in the western United States.

The Intermountain West is currently experiencing increased growth in oil and gas production, which has the potential to affect the visibility and air quality of various Class I areas in the region. The following work presents an analysis of these impacts using the Comprehensive Air Quality Model with extensions (CAMx). CAMx is a state-of-the-science, "one-atmosphere" Eulerian photochemical dispersion model that has been widely used in the assessment of gaseous and particulate air pollution (ozone, fine [PM2.5], and coarse [PM10] particulate matter). Meteorology and emissions inventories developed by the Western Regional Air Partnership Regional Modeling Center for regional haze analysis and planning are used to establish an ozone baseline simulation for the year 2002. The predicted range of values for ozone in the national parks and other Class I areas in the western United States is then evaluated with available observations from the Clean Air Status and Trends Network (CASTNET). This evaluation demonstrates the model's suitability for subsequent planning, sensitivity, and emissions control strategy modeling. Once the ozone baseline simulation has been established, an analysis of the model results is performed to investigate the regional impacts of oil and gas development on the ozone concentrations that affect the air quality of Class I areas. Results indicate that the maximum 8-hr ozone enhancement from oil and gas (9.6 parts per billion [ppb]) could affect southwestern Colorado and northwestern New Mexico. Class I areas in this region that are likely to be impacted by increased ozone include Mesa Verde National Park and Weminuche Wilderness Area in Colorado and San Pedro Parks Wilderness Area, Bandelier Wilderness Area, Pecos Wilderness Area, and Wheeler Peak Wilderness Area in New Mexico.

Directional biases in back trajectories caused by model and input data.

Back trajectory analyses are often used for source attribution estimates in visibility and other air quality studies. Several models and gridded meteorological datasets are readily available for generation of trajectories. The Big Bend Regional Aerosol and Visibility Observational (BRAVO) tracer study of July to October 1999 provided an opportunity to evaluate trajectory methods and input data against tracer concentrations, particulate data, and other source attribution techniques. Results showed evidence of systematic biases between the results of different back trajectory model and meteorological input data combinations at Big Bend National Park during the BRAVO. Most of the differences were because of the choice of meteorological data used as input to the trajectory models. Different back trajectories also resulted from the choice of trajectory model, primarily because of the different mechanisms used for vertical placement of the trajectories. No single model or single meteorological data set was found to be superior to the others, although rawinsonde data alone are too sparse in this region to be used as the only input data, and some combinations of model and input data could not be used to reproduce known attributions of tracers and simulated sulfate.

Reconciliation and interpretation of Big Bend National Park particulate sulfur source apportionment: results from the Big Bend Regional Aerosol and Visibility Observational Study--part I.

The Big Bend Regional Aerosol and Visibility Observational (BRAVO) study was an intensive monitoring study from July through October 1999 followed by extensive assessments to determine the causes and sources of haze in Big Bend National Park, located in Southwestern Texas. Particulate sulfate compounds are the largest contributor of haze at Big Bend, and chemical transport models (CTMs) and receptor models were used to apportion the sulfate concentrations at Big Bend to North American source regions and the Carbón power plants, located 225 km southeast of Big Bend in Mexico. Initial source attribution methods had contributions that varied by a factor of > or =2. The evaluation and comparison of methods identified opposing biases between the CTMs and receptor models, indicating that the ensemble of results bounds the true source attribution results. The reconciliation of these differences led to the development of a hybrid receptor model merging the CTM results and air quality data, which allowed a nearly daily source apportionment of the sulfate at Big Bend during the BRAVO study. The best estimates from the reconciliation process resulted in sulfur dioxide (SO2) emissions from U.S. and Mexican sources contributing approximately 55% and 38%, respectively, of sulfate at Big Bend. The distribution among U.S. source regions was Texas, 16%; the Eastern United States, 30%; and the Western United States, 9%. The Carbón facilities contributed 19%, making them the largest single contributing facility. Sources in Mexico contributed to the sulfate at Big Bend on most days, whereas contributions from Texas and Eastern U.S. sources were episodic, with their largest contributions during Big Bend sulfate episodes. On the 20% of the days with the highest sulfate concentrations, U.S. and Mexican sources contributed approximately 71% and 26% of the sulfate, respectively. However, on the 20% of days with the lowest sulfate concentrations, Mexico contributed 48% compared with 40% for the United States.

Reconciliation and interpretation of the Big Bend National Park light extinction source apportionment: results from the Big Bend Regional Aerosol and Visibility Observational Study--part II.

The recently completed Big Bend Regional Aerosol and Visibility Observational (BRAVO) Study focused on particulate sulfate source attribution for a 4-month period from July through October 1999. A companion paper in this issue by Schichtel et al. describes the methods evaluation and results reconciliation of the BRAVO Study sulfate attribution approaches. This paper summarizes the BRAVO Study extinction budget assessment and interprets the attribution results in the context of annual and multiyear causes of haze by drawing on long-term aerosol monitoring data and regional transport climatology, as well as results from other investigations. Particulate sulfates, organic carbon, and coarse mass are responsible for most of the haze at Big Bend National Park, whereas fine particles composed of light-absorbing carbon, fine soils, and nitrates are relatively minor contributors. Spring and late summer through fall are the two periods of high-haze levels at Big Bend. Particulate sulfate and carbonaceous compounds contribute in a similar magnitude to the spring haze period, whereas sulfates are the primary cause of haze during the late summer and fall period. Atmospheric transport patterns to Big Bend vary throughout the year, resulting in a seasonal cycle of different upwind source regions contributing to its haze levels. Important sources and source regions for haze at Big Bend include biomass smoke from Mexico and Central America in the spring and African dust during the summer. Sources of sulfur dioxide (SO2) emissions in Mexico, Texas, and in the Eastern United States all contribute to Big Bend haze in varying amounts over different times of the year, with a higher contribution from Mexican sources in the spring and early summer, and a higher contribution from U.S. sources during late summer and fall. Some multiple-day haze episodes result from the influence of several source regions, whereas others are primarily because of emissions from a single source region.